PAI Y ELTINAY SCUNTHORPE GENERAL HOSPITAL HISTORY 45 years old male had CT KUB with ho haematuria No renal stones but incidental lesions were identified within the anterior peritoneal cavity ID: 933383
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Slide1
PERITONEAL PEARLS
DEEPAK M
PAI
Y ELTINAY
SCUNTHORPE GENERAL HOSPITAL
Slide2HISTORY
45 years old male had CT KUB with h/o haematuria
No renal stones but incidental lesions were identified
with-in
the anterior peritoneal cavity
There were about seven of them and measured between 9 mm and 22 mm.
They were round to oval in shape and no calcification identified
Slide3NON-CONTRAST CT KUB
Slide4FURTHER SIMILAR FINDINGS
Slide5Slide6History contd
…
Nature and significance of these were uncertain at the time of reporting CT and hence MRI with liver protocol was recommended
Slide7FAT SUPPRESSED T2W AXIAL IMAGES
Slide8FAT SUPPRESSED T2W AXIAL IMAGES
Slide9T1W AXIAL IMAGES
Slide10Slide11POST-GADOLINIUM IMAGES
Slide12INTERPRETATION
It was not clear as these were not enhancing and had no consistent signal characters from all of them.
Any idea?
Slide13BASIC PRINCIPLES
As basic principle in image interpretation, we started digging into the previous imaging studies.
Patient had CT abdomen and MRCP five years earlier
Slide14CT 5 YEARS EARLIER SHOWING NO SUCH FINDINGS
Slide15MRCP 5 YEARS EARLIER
Slide16Patient had gall stones before and we could not find gall bladder on the current CT and MR and hence presumed cholecystectomy in between.
We thought we should check the histology of cholecystectomy specimen
Slide17HISTOLOGY REPORT
Gall bladder measuring 115 mm received and was opened at the fundus.
No calculi. Features of chronic
cholecystitis
.
Slide18DIAGNOSIS
Spilled calculi in the peritoneal cavity during lap
cholecystectomy
Surgical notes confirmed the same
Slide19SPILLED GALLSTONES
Laparoscopic cholecystectomy is a common surgical procedure
Accidental opening of gall bladder is a relatively frequent incident(15-40%)
Spillage of gall stones into the peritoneal cavity can occur in 16-66% of perforated GB
Complications caused by
intraperitoneal
gall stones are infrequent but can be serious
Frequent sites of spillage are right hypochondrium(41%) and pelvis(33%)
Slide20Risk factors for complications are infected bile, pigment stones, male,
perihepatic
location, >15 stones, size >1.5 cm
Time period from spillage to complications varies but average is 5.5 months but can take up to 20 years
Abscess is the most common complication
Anterior abdominal wall and sub hepatic space are the commonest sites for abscess
Slide21Other rare complications are
Fistulas
Adhesions
Intestinal perforations
Intestinal obstruction
Intrahepatic abscess
Spontaneous liver bleed
Obstructive jaundiceNon-infectious collections
Slide22BEWARE
They can mimic peritoneal metastases in asymptomatic patients and in staging CTs if they are not calcified(as in this case)
If there is h/o cholecystectomy then the possibility of spilled calculi has to be considered
Slide23LEARNING POINTS
Any nonspecific findings around the liver and upper abdomen with h/o cholecystectomy should make you think of spilled gall stones
Complications related to spilled gallstones are varied and can be seen up to 20 years after surgery
Reporting Radiologist has a major role in diagnosing them and bring it to the attention of clinicians
Slide24THANK YOU FOR YOUR KIND ATTENTION